Application for membership into the
C.F.P.A.
P.O. Box 1106
Newton, N.C. 28658
www.falange.us

Name: ___________________________________________________________

Address: _________________________________________________________

City _____________________________________________________________

Zip ________________ E-mail address: ________________________________

Phone: ___________________ Occupation: _____________________________

Birth Date: Month______ Day______ Year______

Education: Grade School(_) High School(_) College(_) Some College(_) Other(_)

I here by swear that I _____________________________ am not a Leftist, Racist,

Moslem nor a Mason and that I will abide by the rules and aims of the

Christian Falangist Party of America and that the above information is true, so help me God.